Severe COVID-19 pneumonitis and timing of birth in women
Authors: Clara Calvert, Sarah J Stock
Journal: The Lancet Respiratory Medicine (2023)

There is an extensive body of evidence showing that SARS-CoV-2 infection in pregnancy puts women and their babies at increased risk of adverse outcomes, the most severe of which include maternal admission to intensive care units (ICU), maternal death, stillbirth, and neonatal death.1Allotey J Stallings E Bonet M et al.Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.BMJ. 2020; 370m3320 PubMed Google Scholar However, although pregnant women with SARS-CoV-2 infection face an increased risk of ICU admission, there are important knowledge gaps, such as when provider-initiated delivery should be considered in very sick pregnant women. Available guidance for the clinical management of pregnant women with SARS-CoV-2 from both the UK and the USA, for example, advises an individualised approach to deciding whether an emergency caesarean birth or induction of labour should be done in the case of clinical deterioration leading to concerns for the mother or baby.2Royal College of MidwivesRoyal College of Obstetricians & GyneacologistsCoronavirus (COVID-19) infection in pregnancy.https://www.rcog.org.uk/media/xsubnsma/2022-03-07-coronavirus-covid-19-infection-in-pregnancy-v15.pdfDate: 2022Date accessed: December 6, 2022Google Scholar, 3National Institutes of HealthCOVID-19 treatment guidelines. Special considerations in pregnancy.https://www.covid19treatmentguidelines.nih.gov/special-populations/pregnancyDate: 2022Date accessed: December 6, 2022Google Scholar In The Lancet Respiratory Medicine, Elena Fatnic and colleagues4Fatnic F Lee Blanco N Cobiletchi R et al.Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort study.Lancet Respir Med. 2023; (published online Feb 3.)https://doi.org/10.1016/S2213-2600(22)00491-XSummary Full Text Full Text PDF PubMed Scopus (7) Google Scholar present data from Israel on nearly all women from 13 weeks of gestation up to 1 week postpartum who were admitted to the ICU with COVID-19 pneumonitis from Feb 1, 2020, to Jan 31, 2022. The authors divide this study population (N=84) into four groups: (1) pregnant women who did not give birth during their admission; (2) women who were critically ill on the day of birth (eg, received tracheal intubation and invasive positive pressure ventilation [IPPV]); (3) women who were not critically ill on the day of birth; and (4) postpartum women admitted at least 1 day after birth. The authors show some differences in outcomes between these groups of women with severe COVID-19 pneumonitis, with worse outcomes (ie, requiring IPPV, extracorporeal membrane oxygenation [ECMO], or death) among the women who were critically ill on the day of birth or postpartum women. Later gestational age at SARS-CoV-2 infection has been associated with some pregnancy complications (eg, increased risk of preterm birth5Smith LH Dollinger CY VanderWeele TJ Wyszynski DF Hernández-Díaz S Timing and severity of COVID-19 during pregnancy and risk of preterm birth in the International Registry of Coronavirus Exposure in Pregnancy.BMC Pregnancy Childbirth. 2022; 22: 775Crossref PubMed Scopus (22) Google Scholar) and could play a role in the observed differences in outcomes between the groups, with pregnant women who did not deliver presumably admitted at an earlier gestation compared with the other groups. Only four women were admitted to the ICU in the week following birth, and they were particularly unwell with all requiring IPPV, three women requiring ECMO, and two women dying. This is only a very small number of postpartum women, and there are many potential contributing factors to these poor outcomes—for example, they might not have received appropriate care in labour or might have been sick enough to stimulate immediate labour. It was beyond the scope of this study to provide a detailed multidisciplinary investigation into the circumstances and clinical care preceding and during admission to the ICU for women with poor outcomes. However, in the absence of such detailed investigation, it is difficult to make recommendations around clinical care that might have changed the outcomes in these women and the study serves as a reminder of the importance of maternal death surveillance and response systems (eg, the UK Confidential Enquiries into Maternal Deaths6Knight M Bunch K Patel R et al.on behalf of MBRRACE-UKSaving lives, improving mothers' care core report – lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018–20. National Perinatal Epidemiology Unit, University of Oxford, Oxford2022Google Scholar) and the expansion of these investigations to those who ultimately survived but nearly died. Daily clinical data are also presented in the study— specifically, two different composite scores to capture severity of illness. An improvement in these scores was found following birth among the women not considered critically ill on day of birth; however, there was deterioration in these scores following birth among women critically ill on the day of birth. Although this observation is interesting, we cannot infer from these data when women with severe COVID-19 pneumonitis should be considered for provider-initiated delivery. The women who were critically ill on the day of birth were a very different clinical group to women not critically ill on the day of birth, and it is not particularly surprising that the more unwell women did worse than the less unwell women. There is also an absence of data on other factors that could affect the clinical trajectories and outcomes among pregnant women with COVID-19 pneumonitis, including the status of the baby, the vaccination status of women, the gestational week at infection, and the SARS-CoV-2 variant, which have been associated with the risk of adverse outcomes.7Vousden N Ramakrishnan R Bunch K et al.Severity of maternal infection and perinatal outcomes during periods of SARS-CoV-2 wildtype, alpha, and delta variant dominance in the UK: prospective cohort study.BMJ Med. 2022; 1e000053 Crossref Google Scholar, 8Stock SJ Carruthers J Calvert C et al.SARS-CoV-2 infection and COVID-19 vaccination rates in pregnant women in Scotland.Nat Med. 2022; 28: 504-512Crossref PubMed Scopus (162) Google Scholar, 9Stock SJ Moore E Calvert C et al.Pregnancy outcomes after SARS-CoV-2 infection in periods dominated by delta and omicron variants in Scotland: a population-based cohort study.Lancet Respir Med. 2022; 10: 1129-1136Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 10Prasad S Kalafat E Blakeway H et al.Systematic review and meta-analysis of the effectiveness and perinatal outcomes of COVID-19 vaccination in pregnancy.Nat Commun. 2022; 132414 Crossref Scopus (132) Google Scholar The data presented by Fatnic and colleagues4Fatnic F Lee Blanco N Cobiletchi R et al.Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort study.Lancet Respir Med. 2023; (published online Feb 3.)https://doi.org/10.1016/S2213-2600(22)00491-XSummary Full Text Full Text PDF PubMed Scopus (7) Google Scholar further our understanding of the different trajectories of SARS-CoV-2 illness relative to birth, but the implications for clinical care, specifically around timing for provider-initiated delivery, are less clear. The clinical parameters that feed into the decision to deliver a baby early are complex, and these new data do not push us beyond the current guidelines recommending an individualised approach for women with severe COVID-19 pneumonitis. SJS reports grants paid to her institution from the National Institute of Healthcare Research Health Technology and Assessment, Wellcome Trust, the Medical Research Council, the Chief Scientist Office Scotland, and Tommy's charity; consulting fees paid by Natera to her institution; an honorarium from Hologic paid to her institution for an educational talk; participation on a data safety monitoring board and trial steering committee for the National Institute of Healthcare Research Health Technology and Assessment; and a role as a trustee of the Sands charity. CC declares no competing interests. Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort studyIn patients who underwent delivery during their ICU stay, maternal outcome deteriorated following delivery among those defined as critical compared with non-critical patients, who improved following delivery. Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation. Full-Text PDF